AGED-CARE & RETIREMENT
October – November 2012 | Vol. 7 Issue 1
WE’VE GOT YOUR INDUSTRY COVERED I www.insitemagazine.co.nz
2 I NEWS
MINISTER’S DECISION ON VILLAGE CODE 5 I FOCUS ON:
WOUND CARE AND INFECTION CONTROL: BEING PREPARED FOR BUGS IN AGED CARE FACILITIES
12 I FEATURE
TOGETHER FOREVER? COUPLES IN CARE 20 I REGULARS
ON THE SOAP BOX:
JULIE HAGGIE ON THE REVISED SECTOR STANDARD 16 I CONFERENCES
HIGHLIGHTS OF THE 2012 NZACA CONFERENCE
Do you have questions about living in a retirement village? The Department of Building and Housing provides free independent advice and information for people living in or thinking about moving into a retirement village. Call us free on: 0800 83 62 62 or visit our website www.dbh.govt.nz The Department of Building and Housing is the government agency responsible for overseeing the Retirement Villages Act.
In this issue...
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INsite Magazine Vol.7 Issue 1 EDITOR: Jude Barback T: 07 575 8493 E: firstname.lastname@example.org ADVERTISING: Belle Hanrahan T: 04 915 9783 E: email@example.com PRODUCTION MANAGER: Barbara la Grange LAYOUT Aaron Morey EDITOR-IN-CHIEF Shane Cummings GENERAL MANAGER/ PUBLISHER: Bronwen Wilkins SUBSCRIPTIONS: T: 04 471 1600 F: 04 471 1080 E: firstname.lastname@example.org PUBLISHER’S NOTE: © Copyright 2012. No part of this publication can be used or reproduced in any format without express permission in writing from APN Educational Media (NZ) Ltd.
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Honey, maggots, silver - just some of the alternative treatments re-emerging in wound care.
Being prepared for bugs: the importance of infection control policies in aged care facilities.
Wound care expert AMANDA PALMER discusses how to prevent and manage infection in wound care.
CAROL TWEED discusses pressure injury prevention strategies as outlined in the newly released guildelines.
Till death do us part: JUDE BARBACK looks at the complexities of accommodating couples in aged care facilities.
Attitudes towards the gay and grey: new research about the attitudes of staff caring for homosexuals in residential aged care facilities.
Putting falls prevention into practice.
Alternative treatments re-emerging in wound care
Snippets and updates from the industry
ON THE NIGHT OF 11 September, I found myself falling down the rabbit hole into the annual NZACA conference gala dinner, along with mad hatters, pixies, and all manner of mythical characters. While my fairy wings seemed a rather feeble nod to the theme – an enchanted evening – others had made considerable effort with their attire; the formerly respectable rest home managers, exhibitors, and other members of the aged care sector were barely recognisable. Like nearly everything about the NZACA conference, there was nothing half-hearted about the evening, including the calibre of this year’s Excellence in Care Awards. Care comes in many forms and the awards were testament to this. Among the entries received were blokes’ sheds for dementia units, training and staff development initiatives, and collaborative practice models for transitional active care. In this issue, we focus on a specific and very important aspect of aged care: wound care and infection control. We discuss the importance of comprehensive and regularly reviewed infection control policies in aged care facilities and the need for facilities to provide appropriate education and training to staff, residents, and visitors in this area. Experts share their ‘best practice’ advice on wound care and the treatment of pressure injuries. We also look at alternative therapies used in treating wounds and consider whether there is enough evidence-based research to warrant their use in general practice. Beyond wound care, this issue also sheds light on new research concerning the attitudes of aged care workers towards gay and lesbian residents. We explore this theme as part of a broader look at the challenges facilities sometimes face in accommodating couples. We also explore some of the concerns over waning funding for falls prevention programmes aimed at older people in their homes. Consider this article a ‘taster’ for the next issue of INsite, which will focus on trends in home health. The good news is you don’t have to wait until our next issue to keep up with what’s happening on INsite: we’ve joined Twitter so readers can follow our regular tweets about all things pertaining to aged care and retirement. Jude Barback, editor email@example.com Twitter: @INsite_NZ
NEWS Snippets and updates from the industry
CONFERENCE CORNER...Report on 2012 NZACA Conference
A TYPICAL DAY IN THE LIFE OF... Marge Murphy
LET’S SNOOP AROUND... Whare Aroha Home and Hospital
ON THE SOAP-BOX... Julie Haggie
UP CLOSE AND PERSONAL WITH...Rotha Keo
SPOTLIGHT ON... Technology
RESIDENT CHITCHAT... with Imelda Corby
LAST WORD... Margaret Owens
RESIDENT CHITCHAT... with Imelda Corby
www.insitemagazine.co.nz | October/November 2012 1
News NEWS BYTES
»» INTERNATIONAL OLDER PERSON’S DAY Age Concern celebrated International Day of Older Persons on 1 October at a high tea awards ceremony and campaign launch in Wellington. Age Concern New Zealand president, Evelyn Weir says the campaign highlights the need for older people to be valued. “Dignity and respect are at the heart of all the work we do in serving the needs of older people. We’re calling for New Zealanders from all walks of life to become Dignity Champions and help us challenge attitudes and behaviours which devalue older people,” says Weir. Three awards were presented at the ceremony to recognise those who have championed the dignity of older people. »» BUPA HOME CELEBRATES 50 YEARS Residents and staff of Mary Shapley Care Home and members of the community celebrated the Homes 50 years on Friday 5 October.The celebration was marked with staff from Mary Shapley receiving long service and Careerforce training awards and the official opening of a new 24 bed hospital wing by Mayor Tony Bonne. Local kaumatua Pouroto Ngaropo presented a whaikorero followed by a karakia. Since its opening in 1961 Mary Shapley Home has seen many developments including the expansion of several hospital wings and gardens. Situated on the same property is the Mary Shapley Retirement Village that has 11 apartments currently under construction due for completion in the New Year. »» INTERRAI GETS NOD FROM AGED CARE PROVIDERS Whanganui’s age care providers are showing growing interest in implementing the comprehensive, electronic interRAI Long-term Care Facilities Tool. Whanganui District Health Board (WDHB) health of older people senior portfolio manager Andrea Bunn says interRAI’s reliable, thorough and comprehensive clinical assessment of older adults’ medical, rehabilitation and support needs is proving very effective in identifying potential issues which once addressed, can significantly improve a person’s quality of life. The Ministry of Health wants to see the interRAI tool used nationwide. »» WORLD MENTAL HEALTH DAY Wednesday 10th October marked World Mental Health Day. This year the focus was on depression, with one in six New Zealanders experiencing serious depression. AUT University hosted a special event to mark the day with guest speakers including Sir John Kirwan, Mental Health Ambassador and Dr John Crawshaw, Director of Mental Health from the Ministry of Health.
MINISTER MAKES DECISION ON CODE
uilding and Construction Minister Maurice Williamson has made an important variation to the Retirement Villages Code of Practice 2008, to address the deficiencies of the Code highlighted by the Canterbury earthquakes. Under the revised Code owners of retirement village units will soon be entitled to the original capital sum of their investment following situations like the earthquakes. The variation, which takes effect from October 2013, means deferred maintenance charges will not be deducted from the original capital sum in a no-fault termination situation, such as an earthquake or other natural disaster. The review of the Code started last year after the Christchurch earthquakes revealed several areas where the Code was deficient. Previously, if a village was destroyed and not rebuilt, the residents were only entitled to get back what was set out in the termination clauses in their occupation right agreement (ORA). The RVA felt this was unfair and residents should get back 100 per cent of their original payment in such circumstances. Director of the RVA, John Collyns, declares that the variations made to the code are “perfectly reasonable”. “The revised Code makes things much fairer for residents and is something we’ve been advocating for a long time,” he says. It certainly has been a fairly long road to get these changes incorporated into the Code, but Collyns says the RVA is happy with the level of consultation. Following the RVA’s lobbying, the Minister agreed that the Department of Building and Housing’s preferred changes were to be circulated to stakeholders in June 2012 for a final comment before going to the Minister for a final decision, which has finally been delivered. It is likely the proposed changes concerning insurance provisions were responsible for the slow progression on the revised Code.
Williamson told INsite that the RVA’s proposed requirement, that the operator ensures that the Statutory Supervisor certifies that the insurance cover complies with the Code of Practice, has not been included as there are other parts of the Code that require the Statutory Supervisor’s satisfaction, which is sufficient. “We accept that the insurance issues are far from clear-cut,” says Collyns, “From our perspective, it is important that the Code recognises that insurance cover is not universal throughout the country and can be very expensive. It would be wrong to require operators to have cover when that cover may not be possible to obtain, or at an economic rate.” Minister Williamson told Nsite that the intent of the variations of the Code of Practice align with those proposed by the RVA. “However not all of the wording of the variations aligns with the wording of the RVA proposal,” he says. Gordon MacLeod, chief financial officer for Ryman Healthcare and member of the RVA executive committee, says he is pleased with the variations to the Code. He says no DMF deductions is a position that Ryman has been taking and advocating for some time, and therefore it is pleasing to see this stance reflected in the revisions. MacLeod says he was impressed with how the RVA worked together in a collaborative fashion with the Department and really pushed for a fair outcome for village operators. The Minister agrees. “The Code is a vital tool for ensuring retirement villages work in a fair, equitable way. The variation gives retirement village operators and residents greater certainty,” he says. Now that a verdict has been delivered on the revisions to the Code, the RVA intends to hold a series of briefing meetings for members and associates on the changes and how best to handle them.
In village news Metlifecare has sold its Ilam Park site in Christchurch to Bupa Care Services New Zealand for $9.4 million. The news comes after Metlifecare’s recent merger with Vision Senior Living and Private Life Care, reflecting a shift in focus to the North Island. “Our emphasis is on the premium Auckland, Waikato, and Bay of Plenty markets and we currently have a number of excellent greenfield and brownfield opportunities in the pipeline in these areas,” managing director Alan Edwards told the Herald. Metlifecare recently reported a loss of $141.7 million in the year ended 30 June, from a profit of $20.8 million a year earlier, after it slashed the value of its property portfolio by $99.8 million.
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DISCRIMINATION AGAINST DISABLED HOUSING
More support NOROVIRUS OUTBREAKS SPARK CONCERN for training assessments CAREERFORCE, THE INDUSTRY training organisation (ITO) for the health, aged care, disability, and social services sectors, is introducing a new payment for employers once their trainees have completed qualifications. The Assessment Support Programme will begin on 1 October 2012 and run until the end of 2014. It will apply to all new Careerforce enrolments, and it will cover all levels of training. Once trainees have completed their national qualification, employers will receive a payment calculated at approximately $11 per credit for that qualification. For the Level 2 Foundation Skills National Certificate (43 credits), the maximum payment on completion will be $473 (incl. GST). For the Level 3 Core Competencies National Certificate (57 credits), the maximum payment on completion will be $627 (incl. GST). To achieve the maximum payment, trainees need to complete the qualification in the specified time frame. Ray Lind, chief executive of Careerforce, says the programme intends to promote growth in training and education.
TAURANGA, MIDDLEMORE, AND ROTORUA hospitals, and residential aged care facilities in Gisborne and Whangarei are among those facilities with recent outbreaks of norovirus, a highly infectious bug with symptoms that include vomiting and diarrhoea. The outbreaks have sparked concern at whether current infection control policies in residential and health care facilities are sufficient and being followed correctly. However, experts say that despite precautionary measures at preventing the illness, norovirus outbreaks are difficult to prevent. “Sadly, norovirus outbreaks are a fact of life for rest homes and hospitals,” says Dr Jonathan Jarman, public health medical officer for Northland DHB. “My experience is that rest homes do what they can to minimise the spread of this highly infectious virus once they have an outbreak. It is a very difficult disease to control once it starts to spread,” he says. Jarman says rest homes can face considerable challenges, such as coping with a large number of sick elderly people, sometimes with incontinence or dementia. Staff illness can compound the problem. “It is to the credit of rest homes and their residents if they can control a norovirus outbreak before it affects too many people,” says Jarman. Affected facilities are reportedly following recommended procedures for managing and containing the outbreaks. District health boards typically follow the comprehensive 2009 Ministry of Health Guidelines for the Management of Norovirus Outbreaks in Hospitals and Elderly Care Institutions when providing advice to rest homes, including hand hygiene, restricting visitors, and ensuring any unwell staff remain off work until 48 hours after their symptoms have disappeared. Susanne Scanlen, portfolio manager of health of older people and clinical support at Northland DHB, says that residential aged care providers in Northland have a well developed relationship with the medical officer of health and infection control nurses and in the event of an outbreak their advice is sought. While appropriate measures appear to be taken for managing outbreaks when they occur, recent flare-ups indicate that closer attention needs to be given to preventative measures. As part of their requirement to be certified under the Health and Disability Safety Act, residential aged care providers are regularly audited to ensure they are achieving set criteria, including the standard for infection prevention and control. Scanlen says that after an audit, DHBs have a key role in developing corrective action plans with providers and monitoring their progress in achieving full compliance. DHBs notify and liaise with the Ministry of Health on management of high risks. Jarman says facilities can also learn from virus outbreaks. “A debrief can be a useful activity once an outbreak is over to see if there are any activities which can be improved.”
A RECENT ARTICLE in the Nelson Mail named and shamed regional developers who have allegedly refused to sell land to social housing providers who are looking to build homes to accommodate disabled patrons. Nelson Marlborough District Health Board sought to build a new six-bed home in Stoke or Richmond. However, at the three preferred subdivisions, either the property developers refused to sell or had covenants on sections stopping the land being used for institutional residential purposes. The DHB took the case to the Human Rights Commission (HRC), claiming the refusal to sell land is discrimination against disabled people. However, the developers cited covenants where the land can only be used for residential or a single unit family home as the sole reason for refusal. Andrew Olsen, general manager of Lifetime Design, commends the DHB for bringing the matter to attention but questions whether it is really a matter of discrimination or simply a case of outdated ‘standard’ covenants. “I think it is fair to say that the legalities of property development are vast and complex, and I wonder if some stockstandard elements are ‘copied’ from one document and ‘pasted’ to the next. However, it appears as though some of these standard conventions are at odds with the increasing shift to inclusive communities,” says Olsen. “Whether this is a correct summation of events is up for debate, but as industry professionals, we all have a vested interest in seeing a positive outcome that we can all learn from.” Meanwhile, the HRC has said it is likely to accept a complaint on the issue from the DHB and attempt to resolve it. The HRC says that restrictive covenants used to prevent the provision of affordable housing and social housing is an issue under consideration. Section 53 of the Human Rights Act makes it unlawful to discriminate against someone accessing land or accommodation because of their disability or employment status, but covenants could be phrased in ways which have that effect without being directly discriminatory.
www.insitemagazine.co.nz | October/November 2012 3
HEALTH CARE WALKING THE TALK HEALTH CARE SHONE AT the recent 2012 Equal Employment Opportunities (EEO) Trust Work and Life Awards, with Counties Manukau District Health Board – Health Science Academies winning the supreme award ahead of a competitive field including BNZ, Unitec, and the Department of Corrections. The EEO Trust recognised that the DHB’s initiative was thinking ahead to not only stem a looming shortage of health professionals, but also to encourage Māori and Pacific students to start their training now so they can help care for people from their own cultures further down the track. “South Auckland has a large Pacific population, and what a positive move to encourage youngsters to plan for a future in the local health sector,” says Sally Wenley of EEO Trust. “These students will be able to understand the cultural needs of many patients better than other health workers when they start practising in the industry and this will lead to a more rewarding outcome for them, and their patients.” Shaun Brown, the Bupa Care Service operations manager for the Midland region, was also a recipient of an EEO award. Brown took home the Walk The Talk award, reflecting his commitment to providing supportive environments for colleagues and residents. Employee engagement surveys show that 96 per cent of Brown’s
team enjoy their jobs and resident and family surveys revealed 89 per cent were satisfied with the care provided. Bupa Care Home general manager Grainne Moss says the survey results are reflected in an increase in occupancy and profitability per bed since Brown became operations manager four years ago. One of Brown’s initiatives has been to introduce a ‘falls focus’ team to reduce the number of elderly residents falling. “Working in the elderly care field is a demanding job for any manager and Shaun Brown shone through as a real people’s person who focuses on the welfare of his staff and the elderly people they are caring for. His compassion and understanding is a tribute to him and we hope more people who work in this growing industry of rest homes and elderly people’s well-being learn from his way of successfully and positively managing staff and clients from many different backgrounds,” says Wenley. “His employer, Bupa Care Services, obviously had confidence in his abilities, and the EEO Trust hopes other companies in this industry are doing the same by supporting managers who genuinely care about their employees’ development and the health of the people they are paid to care for.” The EEO Trust Work and Life Awards have been running since 1998 and aim to increase awareness of the business benefits of supporting diversity and the benefits of helping employees meet their commitments at work and at home. There were a record number of entries for this year’s awards, with 62 workplace initiatives across five categories.
New dementia e-learning tool THE NORTHERN DISTRICT Health Board Support Agency (NDSA) has developed an e-learning tool that provides real-time information and advice for those wanting to gain a better understanding of the mental health issues that older people face. “Dementia, depression, anxiety, and personality issues can be just as challenging for the person experiencing them as they are for those who do the caring – something I think is sometimes overlooked,” says Whanganui District Health Board mental health & health of older people senior portfolio manager Andrea Bunn. The e-learning tool asks web users to identify themselves as clinician, service user, carer, and leader/manager. Bunn says while the website was designed by clinicians for clinicians working with older
people, anyone ranging from family members, non-government organisations, caregivers, and clinicians can tailor its use to help them learn more about each topic. The launch of the new e-learning tool coincides with the findings of the recent report released for World Alzheimer’s Day by Alzheimer’s Disease International (ADI), which suggests more education and information is needed around dementia. The report reveals that nearly one in four people with dementia hide or conceal their diagnosis, citing stigma as the main reason, and 40 per cent of people with dementia report not being included in everyday life. The report also reveals that both people with dementia and carers admitted they had stopped themselves forming close relationships as it was too difficult.
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Alzheimer’s New Zealand executive director, Catherine Hall, says the report indicates that stigma remains a major barrier to people affected by dementia getting the help they need. “Our biggest fear is that people are struggling with this disease without the care and support they deserve,” says Hall. It is hoped that resources like the e-learning tool provided by NDSA will contribute to a greater awareness of dementia and other mental health concerns of older people. The e-learning tool is located at www.networknorth.org.nz/e-resources
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Honey. Maggots. Silver. INsite looks at some of the alternative treatments re-emerging in wound care.
ound care practitioners have long been familiar with alternative medicine. The history of wound care is littered with examples of alternative practices. The ancient Egyptians were said to use lint to promote wound site closure, animal grease to provide a barrier to pathogens, and honey as an antibiotic agent. Approximately 3,500 years later, many wound care practitioners still rely on such alternative treatments to aid the recovery of wounds. In fact, alternative – sometimes referred to as complementary or unconventional – treatments are experiencing something of a renaissance in wound care. Many case studies can be found in the recent literature describing wound treatment with substances like honey, sugar, iodine, and even maggots. Today’s patients are demanding more information, more options, and more ability to participate in treatment decisions. To this end, should alternative therapies feature more prominently in practitioners’ approaches to wound care? British researcher, Patricia Davies, believes the management of infected wounds needs to incorporate more treatment options than antibiotics only and suggests older but reformulated wound management preparations, such as iodine, silver, honey, and maggots should be considered. In many cases, practitioners are cautious about using alternative treatments due to a lack of reliable or current research to back up their use. Australian researcher Matthew Leach agrees there needs to be more clinical research carried out in this area. He says existing evidence of safety and effectiveness of alternative treatments is predominantly based on the results of in vivo studies; confirmation from well-designed clinical trials is deficient. Here in New Zealand, alternative therapies have recently come under scrutiny following the failure of an iridologist to refer a client with an invasive cancer in her skull to a doctor. Many believe it is time to include alternative therapists in medical legislation, making them more accountable for their actions. New Zealand Medical Association chairman Paul Ockelford told the Herald that the difficulty with including alternative therapists in the Health Practitioners Competence Assurance Act, which is due for review, is that their practices are not “based on scientific evidence”. However, the editor of Advances in Wound Care, Dr Richard Salcido, urges practitioners to remember that the concept of evidencedbased medicine does not apply only to the
mainstream wound management. Salcido believes this “provides us with a tremendous opportunity to re-examine old treatments and apply them in the current environment”. What are the alternatives? Here we look at some treatments that are making a reappearance in wound care.
New Zealand manuka honey is lauded the world over for its medicinal properties. It perhaps comes as no surprise that the Waikato Honey Research Unit is helping to generate a renewed interest in the medicinal uses of honey, particularly as an effective remedy for wounds and burns. It has also been suggested as appropriate for treating leg, pressure, and diabetic foot ulcers. DermNet suggests that, in most cases, honey is used when conventional antibacterial treatment with antibiotics and antiseptics are ineffective. Studies have shown that these difficult-to-heal wounds respond well to honey dressings. Inflammation, swelling, and pain rapidly subside, unpleasant odours stop, and debridement is enhanced as the honey dressings remove dead tissue painlessly and without causing damage to the regrowing cells. Honey promotes rapid healing with minimal scarring. According to DermNet, there are many features in the composition of honey that together combine to give it its antimicrobial properties. Honey is said to have high osmolality, a saturated or supersaturated solution of sugars that has strong interaction with water molecules. The lack of ‘free’ water inhibits the growth of microorganisms. Additionally, when honey is diluted by wound exudates, hydrogen peroxide is produced via a glucose oxidase enzyme reaction. This is released slowly to provide antibacterial activity but does not damage tissue. Some honeys still have antimicrobial activity even when hydrogen peroxide activity has been removed. Manuka honey has been found to have high levels of this antibacterial phytochemical. In addition to its antimicrobial properties, honey also appears to stimulate lymphocytic and phagocytic activity. These are key body immune responses in the battle against infection.
Although there is little clinical evidence available to support which form of iodine is more effective, it is thought that both povidone and cadexomer iodine are useful in treating wounds. Povidone iodine is available in many forms, including powder, ointment, impregnated gauze swab dressing, spray, and solution. The aqueous
solution, not the alcoholic form, should be used to treat wounds. Cadexomer iodine comes in dressing and ointment forms. It has an absorptive capacity and is thought to provide a sustained release over several days. This form of iodine may be useful in treating infected exuding wounds because of its absorbent properties and prolonged antimicrobial action. Experts recommend that iodine should be used with caution in patients with thyroid disorders and never in those with iodine sensitivity.
Like honey, silver compounds have been exploited for their medicinal properties for centuries. A literature review in Burns revealed that silver has re-emerged as a viable treatment for infections encountered in burns, open wounds, and chronic ulcers. New wound care products have been developed to incorporate silver content. Some existing dressings, including hydrocolloids, foams, films, and non-adherent dressing, have also been modified to include silver. Some dressings release silver ions into the wound, while in others, the ions are locked into the dressing and act on the absorbed bacteria. Research by Thomas and McCubbin suggests that the release of silver ions from dressings appears to have a better response than in vivo.
This one is not for the squeamish! Maggot therapy is still believed to be effective in eliminating bacteria from the wound by altering the pH of the wound fluid to a rate bacteria find unacceptable, secreting an antimicrobial substance, and finally, eliminating bacteria when the maggot ingests the wound fluid and tissue, as the material passes through its gut. The literature indicates that care must be taken in heavily exuding wounds as the maggots may drown in the fluid, and frequent changes of secondary dressings are needed to prevent this from happening. www.insitemagazine.co.nz | October/November 2012 5
Being prepared for bugs JUDE BARBACK discusses the importance of aged care facilities having a comprehensive infection control policy, ongoing education initiatives, evaluative processes, and the ability to react quickly in the event of an infection outbreak.
onditions were ripe for an infection outbreak in Canterbury’s rest homes following Christchurch’s devastating magnitude 6.3 earthquake in February 2011. There were hundreds of residents living in makeshift conditions without running water or working toilets, with used napkins and body wipes to be disposed of, and with liquefaction rising through the floors. There were a few instances. One rest home had a norovirus outbreak that lasted a week, but the facility was quick to respond by closing the doors to visitors, outsourcing its laundry, and coordinating
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staff cover to minimise the spread of the virus. Those who worked with rest homes to ensure no outbreak took place were reportedly amazed there wasn’t a more major outbreak, given the conditions.
OLDER PEOPLE ARE MORE PRONE TO INFECTION
Canterbury’s avoidance of a more serious outbreak among its aged care community certainly does seem miraculous, considering the ease with which infection can permeate an aged care facility, even one not afflicted by an earthquake or other natural disaster. Older people are typically more susceptible to infection due to their compromised immunity, which means they defend themselves less well against infection and disease than younger people. Research published in Journal of Experimental Medicine in 2009 showed that the reduced
FOCUS immunity stems from the inability of an older person’s skin tissue to attract T-cells where and when they are needed. In essence, the study, conducted by scientists funded by the Biotechnology and Biological Sciences Research Council, showed that a normal part of the ageing process contributes to disease and therefore reduces the quality of life in older people. So, given their susceptibility to infection, it isn’t surprising that older people living in close proximity to one another in aged care facilities are at more risk and that infection prevention and control is a top priority for staff. To this end, facilities will typically have an infection control policy in place.
ONE FACILITY’S APPROACH TO INFECTION CONTROL
In the case of Cambridge Resthaven, it is an in-depth 50-page document covering all standard precautions and various guidelines for specifics infections such as MRSA, chest infections, and UTIs. The policy also covers things like when to wear protective clothing and hand hygiene techniques. It outlines what to do and who to contact in the event of an outbreak. General manager Rachel Jones says Cambridge Resthaven’s infection control policy is typical of those found in most rest homes. However, it is tailored to their requirements and influenced by the ‘Bug Control’ manuals and advice from the Waikato District Health Board. Bug Control is an infection control advisory service that benchmarks with a number of aged care facilities. Cambridge Resthaven’s policy is reviewed at least yearly but is also reviewed after any changes suggested by Bug Control or through any recommendations from health professionals, agencies, and the DHB. The infection control policy is complemented by a daily register maintained by the home’s registered nurses, which details any infections residents are being treated for and how they are being treated. The RNs, GPs, and clinical nurse leaders monitor the register to ensure treatment is appropriate and is working. Each month, the clinical nurse leaders, infection control champion (a nurse), staff educator, and general manager review all infections and treatments and statistics are sent to Bug Control for benchmarking. Jones believes education in the area of infection control is paramount. “All staff have infection standard precautions and hand hygiene education on day one of employment,” says Jones. “This is then reviewed and repeated 1-2 months later.”
Hand hygiene is generally acknowledged to be a critical component in keeping infection at bay. Cambridge Resthaven regularly runs hand hygiene audits and informs residents and visitors on appropriate hand hygiene through posters and on a oneto-one basis. The home also runs a generic education day every quarter that covers infection control issues. ‘Older’ staff members who have not had the education in the last year are expected to attend these days along with new staff. Jones says the home is also quick to react to any particular bugs in the community that might affect residents with “impromptu education” for staff and visitors.
It is in the best interests of a rest home to have a comprehensive infection control policy with robust review and education procedures in place. Not only does it help to avoid an infection outbreak, which would inevitably take a huge toll on residents and staff, but it is also among the many things auditors check for in their regular reviews of aged care facilities. Auditors check the policies of the rest home to see whether there are adequate procedures in place to prevent infections spreading between residents and staff. They will also check staff files to see whether staff members have received training in controlling infection. Auditors will typically examine records to see if there have been any outbreaks of infection, and if so, what the rest home did in response.
WHEN INFECTION STRIKES
For all the education and preventative measures a facility might undertake, infection outbreaks can and do occur. The recent outbreak of gastroenteritis at Ryman Healthcare’s Jean Sandel Retirement Village in New Plymouth is an example of how quickly infection can spread through a rest home. With 19 cases in just six days, staff worked hard to manage and contain the outbreak. Visiting was restricted and new patients were refused until the outbreak was over. According to the Taranaki District Health Board, on average, there are six notified gastroenteritis outbreaks in Taranaki rest homes each year. Indeed, the recent outbreak in New Plymouth is an example of the gastroenteritis outbreaks that occur in rest homes and hospitals throughout New Zealand on a fairly regular basis, representing a significant challenge to infection control. In these circumstances, it is important staff are armed with the correct information on cleaning and infection control measures and react quickly to prevent the infection spreading. Isolating patients, suspending new residents, restricting visitors, and informing the necessary people and agencies are among many considerations for a rest home afflicted by an outbreak. It comes back to facilities being prepared and ensuring policies and procedures are robust and regularly reviewed. In this way, facilities stand a good chance of avoiding infection outbreak but will know what to do if they are faced with one.
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Infection control in the management of wounds AMANDA PALMER discusses how to prevent and manage infection in wound care.
reventing and managing infection in wound care can often be challenging. In particular, chronic wounds are almost inevitably going to acquire a collection of various bacteria, likely to include staphylococcus aureus and pseudomonas, along with a mixture of gram-positive and gram-negative bacteria. To imagine that we can stop this from occurring will only lead to disappointment; the key here is to reduce the impact and significance, and importantly, reduce the risk of spreading these bacteria to other clients and patients.
KEEPING HANDS CLEAN
The most fundamental element to any infection control policy is effective hand washing, both before and after dealing with any patient or client. We hear this time and time again, and yet, if we take the time to quietly observe our – and our colleagues’ – hand washing frequency and technique, it is usually apparent that it leaves a lot to be desired! During the SARS outbreak in Toronto, Canada a few years ago, every ward, department, patient, visitor, and staff member were encouraged to clean their hands with hand sanitiser gel at regular intervals. The risk of contracting SARS was at the forefront of people’s minds, and so everyone became far more diligent. Interestingly, this resulted in a significant reduction in cases of infection within the hospital. A coincidence? Or proof that generally we don’t wash our hands as well as we should? Every infection control manual and policy will have guidelines on effective hand washing, and however busy we are, this should be a priority in our everyday practice. This is so important in aged care facilities and where vulnerable people are bought together and the risk of cross-contamination is high.
IMPORTANCE OF CLEANSING
When it comes to wound care, good cleansing is also important to help reduce 8
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the bacterial loading and contamination of the surrounding skin. All too often, dressings are removed, a little saline is wiped over the wound bed, and the dressings are reapplied. This lack of attention towards the surrounding skin can increase the likelihood of infection. Outbreaks of rash-like pustules on the skin can be caused by staph infection, which can be easily reduced and managed through regular effective cleaning of the whole limb or area. Showering or soaking in a bowl of warm water and the use of mild soaps, or in cases of contamination, washing with Chlorhexidine™ wash, can control the opportunistic bacteria. Several studies have been undertaken looking at the benefits of wound hygiene using saline versus warm tap water (where the supply is safe), and there is no evidence of any detrimental effects from tap water. It is high time we gave up the idea of keeping the wound dry and away from water! However, in facilities where patients share baths or showers, cleaning down these areas thoroughly with bleach cleaning agents is essential to prevent cross-contamination.
harbour bacteria and be itchy. However, it is important to ensure the limb is thoroughly washed to prevent the moisturiser building up on the skin, which will in itself cause problems. Slough and necrotic tissue on the wound bed provide an ideal environment for bacteria. Where it is possible to gently remove slough and necrotic tissue, this should be done regularly. Keeping the wound warm and moist will assist in the process known as autolytic debridement, where the action of the body’s macrophages works to break down debris and dead tissue. Where this is not effective enough, sharp debridement should be considered but only undertaken by a skilled and trained member of staff and should not cause pain.
There are many versions of silver dressings available. Unfortunately, the research does not back its use in most cases, and the evidence of its effectiveness is questionable. The inappropriate overuse of these products is likely to lead to the development of resistant bacteria. Effective hand washing,
Every infection control manual and policy will have guidelines on effective hand washing, and however busy we are, this should be a priority in our everyday practice
A simpler idea, where practical, is to line a big bucket with a clean bin sack, which can then be discarded after the patient has had their arm or leg washed. In particular, cavities and sinuses and areas of undermining are excellent places for infection to collect and cleaning should pay particular attention to these areas.
EFFECTIVE WOUND TREATMENT It is also important to apply a moisturiser such as aqueous cream or 50 per cent soft white paraffin and 50 per cent liquid paraffin to the limb/surrounding skin to prevent this becoming dry from washing and being dressed. A build-up of dry skin can
wound and skin cleansing, dressings that manage exudate, and redressing once these have reached their limit are more effective ways of controlling infection. Cross-contamination also comes from strike-through. If a dressing is unable to contain the exudate from a wound, there is a risk of contamination of the environment. If the dressing leaks or if the dressing padding becomes saturated, then every surface the patient comes into contact with will become contaminated: this is a significant risk to other patients. Dressings should have a semipermeable film outer layer to prevent this and also to prevent bacteria travelling from the wet outer layer into the wound bed.
FOCUS Staphylococcus aureus bacteria
Some patients are unable to tolerate adhesives on their skin due to sensitivities or frequency of redressing, but the outer layer of the dressing can be covered with a semi-permeable film dressing such as Smith and Nephew Opsite™, 3M Tegaderm™, or Hartmann Hydrofilm™. This does not necessarily have to overlap onto the skin, though if possible, this is preferable, as it will reduce the risk of leaking exudate. Where there are high amounts of exudates, it is important to use barrier creams such as 3M Cavilon™ or Smith and Nephew Extra Protection Cream™ to prevent breakdown of the surrounding skin under the exudate.
Where the issue of contamination is due to patients who remove dressings inappropriately, a bandage such as Smith and Nephew Handigauze™ or 3M Coban™ can be helpful, as it sticks to itself but not the skin, and once in place, it can be difficult to pull off and will not slacken and pull apart like bandages do. An important point to remember when applying dressings that go right around a limb is not to create a tourniquet effect. The risks here are that oedema can build beyond the bandaging and the edges of the dressing can then cause pressure damage, rubbing, friction, and pain
and damage to the area of the limb where the oedema collects. Where dressings slip or are fiddled with, there is a tendency to want to apply the securing layer firmly to prevent this. If this is the case, the securing bandage/ tubigrip/tubifast should go the length of the limb – for example, toes to knee or wrist to elbow, not just a band around the middle. There are no easy quick-fix answers to dealing with dressings where patients fiddle and remove them, and there is no easy answer on how to reduce contamination, but thorough cleansing of the wound, limb, and of the staff member’s hands at every dressing change can reduce the risk.
KEY POINTS TO REMEMBER: »» Effective hand washing before and after every patient contact is essential. »» Reduce risk of cross contamination. »» Look after the whole (limb or patient), not just the hole. »» Antibacterial dressings should be used with caution and rarely.
References (web-based): Waitemata DHB Wound Guidelines, European Wound Management Association protocols, World Union of Wound Healing Societies protocols, Australian Wound Management Association guidelines, New Zealand Wound Management Association guidelines, Dermnetnz.org, Woundsinternational.com, Global Wound Academy, Cochranelibrary.co.uk Amanda Palmer is a nurse specialist for Wound Management Consultancy Ltd. She will be speaking at the Care Advisory Services training programme, ‘Pain Management and Wound Care’, to be held on 20 November in Mt. Wellington, Auckland. www.insitemagazine.co.nz | October/November 2012 9
Feeling the pressure With ‘International Stop Pressure Ulcer Day’ looming, CAROL TWEED describes some of the strategies for preventing pressure injuries as outlined in the newly released guidelines.
t was burning, BURNING! It was like someone taking a hot poker and sticking it to you!” Imagine living with pain described like this. Recent descriptive research has indicated that pressure injuries are extremely painful, debilitating, and impact significantly upon patients’ daily lives. Pressure injuries (which are also known as pressure ulcers or pressure areas) also incur huge expenditure to our already overburdened healthcare system. Perhaps what is most shocking is that pressure injuries are, in almost all situations, preventable. As providers of health care, this should really make us sit up, take note, and do something about preventing these from developing! Pressure injuries are classified by ACC as “treatment injuries” and claims have risen significantly in the past few years, with an average cost per claim being $1,730. Eight of these have had a fatal outcome. Eighty-eight per cent involve clients between the ages of 65-99 years old. Pressure injuries affect the skin and soft tissue, typically developing over bony prominences but may also develop on other areas of the body exposed to pressure – for example, a plaster cast rubbing, from a catheter tube, or anti-embolic stockings that are too tight.
admitted into our care have a head-to-toe skin assessment undertaken as early as possible in the care episode, paying special attention to bony prominences and other ‘at risk’ areas. Pressure injury risk assessment (using a validated tool such as the Braden or Waterlow) should be undertaken on admission and whenever the patient’s condition changes, and if identified to be at risk, effective preventative actions must be implemented without delay. Combined with these actions is the need to use clinical judgement and ask yourself the question – do I think this patient is at risk of pressure injury in the next 24 hours? The patient should be reassessed the next day. Skin should be inspected for early signs of pressure injury that include: »» persistent skin redness or discolouration (in pigmented skin, discoloration may appear more blue/purple) »» blisters or skin breakdown »» oedema »» localised heat »» localised hardness (induration) of the skin and soft tissue »» patient reports of discomfort or pain. Nutritional screening is also required, and if the patient is identified to be at risk, then they should undergo a more detailed assessment.
2PREVENTATIVE INTERVENTIONS Superficial and deep pressure injuries
Unrelieved pressure, or pressure in combination with shear and/or friction, causes pressure injuries to develop. When we are healthy and mobile, we move without thinking during both night and day to relieve pressure; even during sleep, a person moves on average about every 12 minutes. This intrinsic response to pressure is reduced or absent in someone that is unable to move and/or unable to feel the effects of pressure build-up. Shearing forces occur as a patient slips down in a bed or chair, or if they are dragged rather than lifted along the surface on which they are being nursed. Friction is the superficial rubbing of the skin against a surface or clothing and is exacerbated by the skin being wet or damp (such as through incontinence). There are many patient (intrinsic) factors influencing pressure injury development; the most important have been identified as immobility or reduced mobility, lack of sensation, malnutrition, advanced age, poor blood supply, and poor skin condition. Many of our elderly clients fit into this category, so what can be done to prevent pressure injuries from developing in this vulnerable population? Earlier this year, evidence-based pressure injury prevention and management guidelines were developed and published by the Australian Wound Management Association in conjunction with other Pan Pacific nations, including New Zealand. These guidelines identify three key preventative steps that should occur:
1 DEFINING RISK
Is your patient at risk? Pressure injuries can develop extremely quickly in a vulnerable person – in a matter of just a few hours. That’s why it is so important that all clients 10
October/November 2012 | www.insitemagazine.co.nz
If your patient does not have a pressure injury, but is at risk, then early and effective preventative interventions are required. These should include: »» regular patient re-positioning – the frequency is dependent upon individualised patient needs and the type of support surface they are being nursed on. Use of a specialist mattress does not negate the need for regular repositioning. The 300 tilt, which involves alternating the patient laterally or in a 300 recumbent position, is a recommended positional strategy. For those who cannot tolerate frequent and/or major changes in position, consider more frequent, smaller shifts in position »» use of a constant low-pressure support surface, which should be selected based on factors such as patient needs, patient preference, level of patient risk, patient weight and height, clinical condition, cost, and care setting. The use of layers of pads or incontinence products on top of a specialist mattress is not recommended as it reduces effectiveness and can increase the heat and moisture retentiveness of the skin. If the patient sits up, remember that this should be for a limited amount of time (maximum two hours) as sitting increases the amount of pressure put through the sacrum and pelvis. Also use a pressure-redistributing cushion in the chair »» protecting the skin by eliminating friction, shear, and moisture. This includes positioning the patient appropriately so that they are not sliding down the bed and also when repositioning the patient, safe and effective methods are used so that the skin is not rubbed or dragged. Patient transfer assistive devices should also be used where appropriate so that independence is promoted. Skin should be cleansed using a pH-appropriate cleanser and protected where appropriate. A water-based skin emollient can be used if necessary to help maintain skin hydration »» considering the use of a high-protein supplement in those identified to be at risk and involving the dietitian in the patient’s care
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»» educating your patient and significant others is important in attaining cooperation in preventative interventions. Patients and their care-givers should have a clear understanding of the impact of having a pressure injury and the importance of prevention. This is particularly important when the patient is in a home care setting or being discharged into one. »» Continuing to assess risk and evaluating the effectiveness of interventions on a daily basis.
»» All assessments. »» All management plans. »» All interventions. “If it isn’t recorded in the notes, the starting point is that it didn’t happen” – a quote from the Health and Disability Commissioner (2011), who highlighted how good clinical records are integral to providing care. “Regular turns”, “skin intact”, and “all cares given” are all commonly written about pressure area care, but what is meant by this? If you write things like this in your clinical notes, then think again! What does ‘regular’ mean? Once a day? Once every two hours? It’s just not clear. Use words such as ‘patient re-positioned every two hours’. What does ‘skin intact’ mean? We know the skin could be intact but there could be significant discolouration indicative of a deep tissue injury and heralding a grade 4 pressure injury. Use terms such as ‘skin intact but has persistent redness that does not blanch on light finger pressure’. Think about use of medical photography if you have access to it. What does ‘all cares given’ mean? You need to be specific about what care was delivered and when and by whom. Notes should be up-to-date, clear, concise, and meaningful.
When patients develop pressure injuries and complaints are made, recurring themes are: »» that guidelines have not been followed »» there is poor documentation »» specialist support surfaces have not been provided early enough »» specialist equipment has not been maintained (typically put in the cupboard broken, where it stays until the next patient needs it – then it cannot be used) »» risk assessment is undertaken as a paper exercise and then no further action is taken »» education and training have not occurred. Check that your institution does not fit into this category! It is part of the duty of care we owe our patients.
Pressure injuries are a major global healthcare problem occurring in both acute, long stay, and community healthcare settings, most frequently affecting frail patients with reduced mobility and complex co-morbid conditions. Pressure injuries are, however, an indicator of the quality of delivered care, and it is increasingly being seen as unacceptable that patients develop these nosocomial lesions. Although frequently seen as the role of nursing staff, as pressure injuries impact so greatly upon patient care outcomes, it is also important that other healthcare professionals are aware of the causes and methods of preventing them. Evidence-based practice works but it needs proactive implementation. National guidelines are now available and these should underpin a quality healthcare agenda. On 16 November, there will be an International Stop Pressure Ulcer Day, with a large number of countries are participating. For New Zealand, the New Zealand Wound Care Society is running the campaign with posters and education sessions. The aim of the campaign is to raise awareness of this preventable condition and to create national support in preventing these conditions from occurring in vulnerable patient groups. The guidelines are free to download and print, or a print copy can be purchased from the New Zealand Wound Care Society website (www.nzwcs.org.nz).
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www.insitemagazine.co.nz | October/November 2012 11
Till death do us part
JUDE BARBACK examines some of the difficulties couples face in remaining together in old age.
any a marriage proposal has featured the words “I want to grow old with you”. Without wanting to detract from such a romantic notion, ‘growing old together’ can become problematic when health concerns threaten to split a couple in different directions, particularly if one requires residential aged care before the other. This was the case for Napier couple John and Verona Moynihan. Eighty-year-old Mrs Moynihan, a double amputee of 67 years and described by her husband as a “happy, healthy, free spirit”, was admitted to hospital at the beginning of this year after a nasty fall at the GP surgery. Upon assessment in hospital, specialists deemed Mrs Moynihan unfit to return home, on the basis of their concerns over her physical and mental health, and she was consequently placed in care at Princess Alexandra Home. The decision brought anguish and heartache to the couple, who hadn’t been apart in over 58 years. Mr Moynihan emphatically disputed the assessment, maintaining that as he has power of attorney for her personal care and welfare, the decision on where she lives should lie with him. In correspondence with the Hawke’s Bay District Health Board, he denied that the clinical opinions of the specialists had any relevance, citing the New Zealand Bill of Rights Act 1990, s 11: ‘everyone has a right to refuse to undergo any medical treatment’. The DHB and specialists involved defended their decisions about Mrs Moynihan’s care and remained adamant she required “long-term hospital-level care, 24 hours a day”. Hawke’s Bay chief medical officer, Dr John Gommans, says the DHB aims to support people to stay at home with their families as long as practically
possible. However, there remains a duty of care to ensure their safety and wellbeing. Eventually, Mrs Moynihan was released back home after the specialists were convinced that her health had improved and she had adequate support at home, but the story highlights the grim reality of how poor health can tear an ageing couple apart.
says Evans. Some facilities have found that adjoining rooms provide a good solution for couples in this category. Among them is Tauranga rest home, Bethlehem Views, built just over a year ago. However, manager Diane Roger says that in practice such rooms are seldom used as they were intended. With no one currently requesting such rooms, they remain occupied by individual residents with CATERING FOR COUPLES the adjoining door locked. Roger says they Even couples who have the means and the would not move residents from room to room, foresight to move to a retirement village that which, while undoubtedly the best decision, includes a care facility while they are both still creates a conundrum. Such rooms are only fit and healthy can find themselves having to ever likely to be filled by couples if they are make the bleak choice between separation and vacated at the exact time they are required by quality care. The inclusion of a care facility a couple. And that is not taking into account within a village is no guarantee that they will be the complexities of waiting lists. Selwyn able to accommodate a couple at any given time. Foundation encounters a similar conundrum. It can be tricky second-guessing demand. If “We do have two rooms with an ensuite there are no couples wanting the double room, between and the couple use one as a bedroom a care facility will understandably fill the room and the other as a lounge. They are not kept open with a single occupant. for couples as demand for beds is so high,” says While no reliable statistics are available on Evans. Selwyn also has some bigger rooms that the matter, anecdotal evidence shows that it can accommodate a couple, if needed, as well is fairly uncommon to have couples wanting as ‘flatettes’ – a set-up comprising a bedroom, to share a room in an aged care facility. When bathroom, and lounge that allows rest homeasked about NZACA members’ experience, level care. chief executive Martin Taylor said, “It is not Generally, Selwyn’s policy for couples that common, I am told. Many facilities do have requiring different levels of care at different times double rooms, but most couples like their own is straightforward: the one who needs to move is room at that age.” moved, while the partner stays in the home. However, this isn’t always the case. “They are able to share meals with their “It depends on the couple; some like to partner in the rest home/hospital and spend as have a double bed, which is fine – age is not much time as they wish with their partner,” a factor,” says Su Evans, admissions officer says Evans. for Selwyn Foundation. Evans tells me of a It is a similar story at Metlifecare. couple who were married for 71 years and “If there is a room that can accommodate who resided in one of Selwyn Heights’ double a couple, it is not necessarily reserved for a hospital rooms. “We added a cat door, so that couple,” says Lynne Abercrombie, Metlifecare’s they could have their moggie with them,” general manager for operations.
Attitudes towards the grey and gay New research examines the views and experiences of staff caring for older homosexuals in residential aged care facilities. ACCORDING TO THE findings of a study that looked into the attitudes of New Zealand aged care workers towards gay men and lesbians in their care, sexual orientation has little influence on staff’s ability to care for residents. It was found that the transition into residential care tends to be an unsettling time for all people, and regardless of sexual orientation, good assessment and developing relationships are essential. Interestingly, other research shows that the same attitudes are not exhibited in aged care facilities across the Tasman. An earlier report from Western Australia had concluded that older LBGTI (lesbian, bisexual, gay, transgender, and
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intersex) individuals accessing retirement and residential aged care facilities experienced high levels of unmet needs and fears of discrimination. A 2010 article in the Sydney Morning Herald highlighted the problem, with Adelaide gerontologist, Jo Harrison, describing the aged care situation for the gay community – with lack of services, awareness, and funding – as “at crisis point”. In New Zealand, there is an increasing awareness of the unique issues faced by sexual minorities as they age. Research began to emerge in the 1970s that suggested societal stigma, such as ageism, and the potential
for institutionalisation and the lack of legal recognition of gay relationships may cause difficulty for older gay men. After the New Zealand homosexual law reforms of 1986, there was still no guarantee that homosexuals would not continue to be identified as pathologically unwell by health professionals. Unitec student Bernie Kusher’s research in 2010 revealed the concerns and fears held by many older gay men about going into a long-term care environment with predominantly heterosexual staff and residents. Accordingly, the recent New Zealand study was conducted by University of Auckland researchers, with Massey University researchers and representatives from health and social care organisations, to discover more about the perceptions of aged care workers towards homosexual residents. The research involved three district health boards in the Auckland region, with 47 staff from seven residential aged
FEATURE “If the room becomes available and there is no demand from a couple for the room, it will be given to a single person making an enquiry. If a subsequent enquiry arose for a couple, the single resident may be asked to relocate but not required to relocate. It depends on if there is another room available and if that room appeals to the person currently occupying the double room. The resident is not compelled to move, but in some instances, is happy to move,” says Abercrombie. Metlifecare, like most providers, aim to accommodate the individual choices of the resident. “Some married couples prefer adjoining rooms, others a shared room with single beds, some a shared room with a double bed. We do the best we can to accommodate the potential resident’s or residents’ desire against the background of care and support each individual has,” says Abercrombie. “For some couples, they would want to remain together whatever the circumstances. For some couples, if one is approaching end of life, they may not wish to die in the home
that their partner is going to continue to live in. For others, their care needs require a level of support that cannot be safely provided in the home. Our driving philosophy is to support the resident in the choices they make. To enable this, we try to provide flexible care options where possible while ensuring both residents are safe,” says Abercrombie.
care facilities participating. Case scenarios of older gay and lesbian residents living in aged care were used to facilitate discussion. While the study showed staff to generally have no issues with residents’ sexual orientation, it revealed that their main challenges were dealing with the homophobic attitudes of other residents. Many staff attributed such behaviour to the high levels of cognitive impairment among some residents. It is important to consider the historical context. Many older people grew up at a time when homosexuality was criminalised and lesbianism was vilified, thus affecting their perceptions. Similarly, growing up at this time means trust is an important issue for older LBGTI residents. By contrast, participants said that knowing family members, friends, and colleagues who identified as lesbian or gay helped in their ability to empathise with LBGTI residents.
Indeed, it is important for care workers to develop trusting relationships with all residents. Personal privacy is seen as a fundamental right for all older people in aged care, and staff acknowledge the importance of being able to help ensure personal privacy, along with partner involvement in care. The research, which was funded by the Rule Foundation, a charitable trust, also identified the importance of the role of community organisations that advocate on behalf of the older LBGTI community. “I think it is important that the expertise is out there and that aged care facilities can tap into this,” says Dr Gary Bellamy, a research fellow in the School of Nursing at The University of Auckland. “There is great value in making sure that staff are aware of what is available.” The professional conduct of staff is influenced, in part, by the nature of their job. For example,
SEXUALITY A TRICKY SUBJECT
Aged care facilities have more than logistics to consider when welcoming a couple. Dr Laura Tarzia, researcher at Australian Centre for Evidence Based Aged Care, says sexuality can be a difficult subject for families and staff to broach. “You get couples who have been living together for 50 years and then they move into a residential care facility. Suddenly, they have to have separate beds, and that can be quite distressing for them,” says Tarzia in an interview with Shots, NPR’s Health Blog. Tarzia’s recent report in the Journal of Medical Ethics found that although no law forbids intimate relationships between people
in nursing homes, staff and family members often discourage residents, especially those with dementia, from expressing their sexuality. “I think it’s even more difficult for people who form new relationships in a residential care facility because then staff don’t really always know how to deal with it and sometimes families have objections,” says Tarzia. Tarzia believes that while decisions about intimacy shouldn’t be made by family members in the same way as power of attorney decisions relating to financial or legal matters, there is a need for staff and family to discuss the matter with residents. Of course, sex shouldn’t be taken lightly, either, given the associated health risks. Tarzia says it’s important that staff in care facilities be willing to discuss the use of condoms for the prevention of sexually transmitted diseases. Kim Brooks, director of nursing at Metlifecare, acknowledges that relationships do develop in all areas of their villages. “We have specific sexuality and intimacy training sessions for staff, remembering that this is the residents’ home and we support their wishes as much as possible with privacy.” Education in this area is important. Experts say the baby boomer generation, on the cusp of aged care, tend to have less conservative attitudes towards sex, and therefore, sexual health should be taken seriously by staff and families. A study published in the Student BMJ shows that the rates of sexually transmitted disease among baby boomers have doubled in 10 years as fewer are practising safe sex.
MORE COUPLES IN AGED CARE
With the baby boomer influx and the average life expectancy steadily increasing, there are bound to be more couples than ever ready to enter aged care facilities together. District health boards, rest homes, hospitals, and villages are going to need to prepare themselves for the challenge of providing the necessary care for two people with different needs but a common interest in continuing to live together. registered nurses in New Zealand work within a prescribed code of conduct and have legal and professional responsibilities towards patients. However, unqualified caregivers who are involved in direct care receive most of their training ‘on the job’. The attitudes of medical staff, nurses, and other caregivers can impact significantly on acceptance and understanding of the unique perspectives of the LBGTI residents. The findings from the study are being used to develop some practice guidelines for staff working in aged care facilities. The intention is to follow this project with a study of the views and experiences of older gay, bisexual, and lesbian people and their partners regarding residential aged care. “The project is a first for New Zealand and will help to raise awareness of the unique needs of people from sexual minorities as they age,” says Dr Bellamy.
www.insitemagazine.co.nz | October/November 2012 13
Putting falls prevention into practice Falls prevention remains a key focus for researchers, but are changing funding policies impeding the right information reaching older people at risk of falling in their homes?
s a person ages, the likelihood of them falling increases. A person over 65 years old has a one in three chance of falling in a year, a risk that increases to a one in two chance for those aged 80 and over. As balance wanes, muscles weaken, vision becomes more impaired, and medical conditions take their grip, older people can find themselves at risk of falling even within the most familiar environments. Falls can be devastating for older people. Beyond the possibility of cuts, bruises, and broken bones, there is the blow to their confidence that really takes its toll on their ability to live independently. Research shows that the knock-on effect of a fall is significant: if a person falls and loses confidence, they are likely to exercise less, thereby reducing their muscle condition and increasing their risk of another fall. Beyond the physical and social aspects, there are the economic costs to consider. Falls often result in an older person needing to move into hospital or rest home-level care, placing further burden on a health budget already under strain. New Zealand has long been heralded as a world leader in falls prevention. Drawing on a vast body of research, the Otago Exercise Programme (OEP) is recognised internationally as an effective method for helping to reduce the number of falls in older people. For those eligible – typically those over 80 (or over 65 for Māori and Pacific) living independently who are deemed to be at risk of falling – the programme involves a provider visiting the person six times during a year to assess health, strength, and balance and to teach and monitor a series of exercises. All evidence suggests that the OEP is an excellent initiative. A growing bank of participants’ success stories helps to back up the claim that the programme is proven to reduce falls and fall-related injuries by 40 per 14
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cent. Eighty-seven year old Rowley features among these case studies, proudly announcing his recent avoidance of a fall when he tripped and was able to quickly regain balance, something he attributes to the OEP. However, despite its acclaim, the programme no longer receives public funding. ACC formerly funded the provision of the OEP to eligible seniors but withdrew its funding for the programme nearly two years ago. Nick Conn, director of Willis Street Physiotherapy in Wellington, says that prior to ACC’s funding withdrawal, his team delivered the OEP to 620 individuals per year in the Wellington and lower North Island area. Now this figure is reduced to a mere one or two privately funded patients per year. “The OEP is now delivered only in small pockets and poorly funded,” says Conn. “The only area that I am aware of which has a larger programme running is Canterbury, where the DHB fund it.” The only loophole that might see an older person receive partial cover from ACC for the OEP is if they have a fall, lodge a claim with ACC, and find an OEP provider who can claim a partial payment from ACC for each session. It would appear the attitude towards falls is becoming increasingly more about reaction than prevention. The OEP is not the only programme to fall victim to a lack of funding. More recently, ACC also withdrew its funding for modified Tai Chi, another programme
proven to improve strength and balance and decrease falls. The ACC funding had enabled organisations to train approximately 1000 modified Tai Chi leaders, but funding was withdrawn on the grounds of not being costeffective. It would be easy enough to jump aboard the ‘let’s berate ACC’ bandwagon at this point, but it is fair to say the organisation has continued to show its support for initiatives like modified Tai Chi and the OEP. Its website is brimming with information on such programmes and on keeping older people safe at home. Yet with its funding pared right back, it is hard to believe that falls prevention is given the same importance it was several years ago. According to its website, ‘in the short term, ACC is focussing on delivering low-cost evidence-based fall prevention programmes such as the Vitamin D programme’. As a result of ACC’s retraction of funding in this area, the onus has fallen increasingly on district health boards (DHBs) to fund such programmes. Of the additional funding received from the Government for hospital and community services in recent years, most DHBs have, in turn, offered small increases to providers of community services, which help ensure older people are safe in their home. However, the changes have left the general public and even health professionals confused about the options open to them, begging the question of whether falls prevention for older
FEATURE people in the community is still being given the attention it warrants. Yet despite some ambiguity around funding, the emphasis on falls prevention remains strong and is a key focus of the New Zealand Injury Prevention Strategy 2005-2015, with DHBs, national agencies, and community organisations all involved in providing awareness campaigns and programmes around falls prevention. The Canterbury Clinical Network is a notable example, leading the way with its community-based falls prevention programme, which is specifically funded to reduce the number of elderly sustaining falls-related injuries. The programme is executed by ‘falls champions’ – typically physiotherapists or registered nurses dedicated to primary care in geographical clusters to provide falls prevention services to elderly clients in their homes. The falls champions support community service providers and retirement villages in falls prevention strategies, such as the Modified Otago Exercise Programme (MOEP). They also mentor volunteers to deliver ‘Stay On Your Feet’, a programme based on the MOEP but aimed at a slightly younger, more active population.
Waikato DHB has also gained recognition for ‘Upright’, its falls minimisation programme. Although primarily aimed at hospital patients, plans are under way for rolling out the falls prevention programme to the community, with Rural and Community Services staff completing the Upright online education programme. Age Concern has been instrumental in promoting awareness of falls intervention throughout the country with programmes like ‘Step ahead’, ‘Steady as you go’, and ‘Sit and be fit’, all aimed at maintaining and improving strength, balance, and mobility. Conn says community-based exercise programmes are good for those fit and active enough to participate, but for a house-bound older person, their options are likely be fewer. “They may be able to access community physiotherapy through a GP referral,” he says. New Zealand researchers continue to churn out leading research in the field of falls prevention. It seems the concern is not the level of importance placed on falls prevention for independent older people, rather the level of funding for
programmes in this area. While commitment to falls prevention programmes appears to remain strong, the challenge will be to retain emphasis in preventing, rather than reacting to, falls.
INTERVENTIONS TO PREVENT FALLS: »» strength or balance training »» medications review »» vitamin D supplements »» vision assessment »» home hazard assessment »» taking into account individual risk factors. Source: wwbpac.co.nz
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www.insitemagazine.co.nz | October/November 2012 15
2012 NZACA CONFERENCE
New Zealand’s aged residential providers flocked to Rotorua in September for the New Zealand Aged Care Association’s annual conference.
his year’s NZACA conference was all about the future directions for aged care providers, about going ‘deeper’ and ‘wider’. In many respects, the conference posed more questions than it answered – or at least developed a greater understanding of particular issues affecting the sector. “We certainly gained a better understanding of the barriers to going wider,” says NZACA chief exceutive Martin Taylor, acknowledging those barriers as “finding the right people in Government to talk to” and devolving services to the private sector. Taylor believes that in spite of a general willingness from the Government and district health boards to go ‘wider’, unless plans for expansion are made at least five years out, it is unlikely to happen. “The capital investment will simply not be there,” he says. Taylor concedes the complexities surrounding public-private partnerships are a major factor to take into consideration in moving forward. Taylor reported that NZACA’s strategic goals and outcomes were completely supported by members, particularly some of the more difficult issues the association is facing, such as underfunding in the sector and Government resistance to supporting practical premium charging. The issue of premium charging did not prove to be any less contentious after Associate Minister of Health, Jo Goodhew addressed it at the conference. The Minister’s talk of finding a balance between providing choice and affordable care options for all who need it, when they need it, left many residential care providers still uncertain about the future of this issue. The sticking point remains whether a facility can refuse entry into a premium room if the potential resident cannot pay for the premium service. The programme was peppered with a mix of broad international experience and
October/November 2012 | www.insitemagazine.co.nz
TELECOM COMMUNITY CONNECTIONS AWARD & INsite OVERALL EXCELLENCE IN CARE AWARD – PERIA HOUSE
QPS BENCHMARKING INNOVATIVE DELIVERY AWARD
JACKSON VAN INTERIORS BUILT AND GROWN ENVIRONMENT AWARD
HEALTH ED TRUST TRAINING AND STAFF DEVELOPMENT AWARD
NZACA/INsite EXCELLENCE IN CARE AWARDS TELECOM COMMUNITY CONNECTIONS AWARD Peria House – Men at Work Revisited – Thank Goodness for the Shed – People, Partnerships, and Prosperity! HEALTH ED TRUST TRAINING AND STAFF DEVELOPMENT AWARD Elizabeth Knox Home and Hospital – Training and Staff Development innovations to improve education, wellbeing, safety, and staff satisfaction. JACKSON VAN INTERIORS BUILT AND GROWN ENVIRONMENT AWARD Kenwyn Rest Home and Hospital – The Rose of Te Aroha QPS BENCHMARKING INNOVATIVE DELIVERY AWARD Althorp Private Hospital – Transitional Active Care Scheme: A collaborative practice model INsite OVERALL EXCELLENCE IN CARE AWARD Peria House
CONFERENCE economist opinions, which helped to add different perspectives to more local issues. Karima Velji, a leading light in Canadian aged care, posed some bold questions for the sector in general, suggesting that we need to challenge our perspectives about care provision to older people and outcomes. Ingrid Williams of Australia looked specifically at transitional care, how to effectively manage the interface of acute and residential aged care.
Among the many entries for the awards, it was Peria House’s ‘Bloke’s Shed’ that took the supreme award for overall excellence in care at the recent 2012 NZACA conference in Rotorua. The Opotiki rest home, in partnership with Alzheimer’s Eastern Bay of Plenty, established a ‘Bloke’s Shed’ aimed at meeting the needs of men with dementia within the rest home, as well as those in the community still living at home.
Cam Ansell of Grant Thornton drew interesting comparisons between the New Zealand’s residential aged care market with those in Australia, Denmark, the USA, and the UK, looking at the changing models of each and the striking similarities and differences with our own sector. From international statistics, Ansell suggested public awareness, innovation, and competitiveness, transparent care funding, a productive workforce, and visionary, adaptable, and united providers were the ingredients to a successful aged care model. For all the inevitable distraction of politics and economics, the focus of the conference remained on care. In particular, the break-out sessions on dementia care topics were well received, sparking many discussions over tea cups in the breaks that followed. Tea cups were substituted for champagne flutes at the conference gala dinner, which bore the theme ‘An Enchanted Evening’. All manner of fairyfolk populated the tables to celebrate the recipients of the NZACA/ INsite Excellence in Care Awards.
The initiative also earned Peria House the Telecom Community Connections Award. Elizabeth Knox Home and Hospital of Auckland won the Health Ed Trust Training and Staff Development Award for their training and staff development innovations to improve education, wellbeing, safety, and staff satisfaction. Te Aroha’s Kenwyn Rest Home and Hospital took away the Jackson Van Interiors Built and Grown Environment Award and Tauranga’s Althorp Private Hospital was the recipient of the QPS Benchmarking Innovative Delivery Award, with its transitional active care scheme. While the winning facilities can be justifiably proud of their awards, the high standard of all the entries is a reflection of the calibre of care delivered throughout the sector. In addition to providing a platform to discuss the pertinent issues and take them to the next level, this year’s conference also gave an opportunity to celebrate the successes of the many people comprising the aged care sector and doing an excellent job.
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www.insitemagazine.co.nz | October/November 2012 17
A typical day in the life of …
MARGE MURPHY MARGE MURPHY gives an insight into her job as a wound care nurse specialist for the Waitemata District Health Board (DHB).
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ecause of the vision of Dr Michal Boyd, Waitemata DHB is fortunate to have a wound care nurse specialist dedicated to the aged care sector. My interest in wound care was established while I was district nursing in London. I had also spent some years managing aged care facilities in central Auckland in the 1990s, so when the job was advertised, I was sure the job was made for me. It hasn’t been a disappointment. My day-to-day work is made up of visiting residents to do assessments and providing the best evidence-based treatment. I support the staff in writing care plans and the provision of dressings for the first three to four dressings. This has benefits for the staff, patients, and the DHB, giving the staff time to access appropriate dressings while ensuring patients get the best available treatment, and I hope, on occasions, averting admissions to hospital. Education underpins the ethos of the role, and I provide one-to-one training or group sessions. I try to tailor training to their individual needs. We also provide a half-day training session to all staff yearly. These sessions are well attended. I belong to a group of passionate and visionary gerontology nurse specialists who work on a day-to-day basis in the aged care sector. Establishing and maintaining
wound care products being constantly introduced. I am aware of the financial limitations of the industry and the budgetary constraints. I train the staff in the use of more efficient products that are more expensive up front, but in the long run, cost less by being able to be left on longer and using less nursing time. It is a privilege to work with the elderly – they are a generation who really knew what hardship was and have a great appreciation for life and living. I am regularly given pearls of wisdom. I cover Auckland’s east coast from Devonport to Algies Bay, so I can sometimes drive up to 30 to 40 kilometres a day. It is just a great feeling when I finish a really productive day where I have helped staff to have a greater understanding of how to provide the best care for their patients, and have improved
I belong to a group of passionate and visionary gerontology nurse specialists who work on a day-to-day basis in the aged care sector. Establishing and maintaining great relationships with all the staff is one of the benefits of the role great relationships with all the staff is one of the benefits of the role. I love seeing the familiar faces when I walk through the hospitals and rest homes and get offered many cups of coffee and morning teas. Unfortunately, all too often, staff move on, which we know is one of the challenges in the industry. One of the biggest challenges for me is staying informed on the plethora of new
a patient’s quality of life by being able to carry out a thorough assessment and provide treatment that is comfortable and acceptable to the patients. I am fortunate to drive down that beautiful coastline with not a cloud in the sky and head towards North Shore hospital driving my sports convertible. Being Irish, I love talking, wounds, and driving, so I have found my perfect job.
Let’s snoop around...
Whare Aroha Home and Hospital M y decision to select Whare Aroha for this issue’s ‘snoop around’ could possibly be seen as a lazy choice, given that it is a mere five minutes’ walk from the Rotorua Energy Events Centre, the venue for this year’s NZACA conference. Convenience aside, Whare Aroha is undoubtedly in a fantastic location, within a stone’s throw of the city centre, the lakefront, and Government Gardens. Having allowed unnecessary ‘getting lost’ time, I find myself at Whare Aroha ahead of schedule. I like being early – sitting in the reception area pre-snoop, observing the facility as it goes about its business, is usually more telling than the interview and guided tour itself. The waiting area at Whare Aroha is in the corridor. From here I am privy to the banter of the reception staff, which is entertaining in itself. Residents wander past me sporadically, one stopping to ask me if I’m applying for a job here, another commenting on the stunning and fragrant vase of lilies beside me. Visitors come in and out: grandchildren, children, spouses – all are greeted enthusiastically by the reception team, and I start to feel like I truly am in a home, rather than a facility. While it has been recently redecorated in a tasteful palate, it is clear that Whare Aroha, as a building, was built a long time ago as a nurses’ home for Queen Elizabeth Hospital. Unlike modern facilities, there are no ensuites, and many rooms have been converted from other uses rather than purpose-built. Manager, Thérèse Jeffs, makes no apology for the building. “We’re not a flash building, we’re not The Ritz,” she says. “Our focus is on The Ritz care.” Thérèse’s care philosophy hinges on the Eden alternative model, which is based on the core belief that ageing is part of our life journey, rather than a period of decline. Her main goal is to create a homely environment, and in the four months she has been managing Whare Aroha, Thérèse and her new management team have brought about many changes to achieve a feeling of homeliness. The garden has had an overhaul, and while a blustery Rotorua day prevents me from having a good nosy, I can see that it has been beautifully done. The interiors have all been repainted, with hues of chartreuse, burgundy, and a pretty duck-egg blue appearing throughout, with complementing furniture. I sense the renovations have been a big deal for staff and residents alike. “I think you need to increase our insurance ’cause it’s so flash now,” says resident Chris to Thérèse as we pass through a newly redecorated lounge. Then there are the resident animals. Among the pets is Monty, a white Chihuahua-Maltese
Visitors come in and out: grandchildren, children, spouses – all are greeted enthusiastically by the reception team, and I start to feel like I truly am in a home, rather than a facility
cross, who is doted on by the residents. I meet Monty in the Manaia Suite (dementia unit), where he spends most his time. Today, he is wearing a pink bandana, which is causing some consternation among the residents. After all, Monty is a boy. The dementia unit is home to 21 residents; there are also 21 rest home beds and 36 hospital beds. Although the building itself was built in the 1950s as the nurses’ home to the nearby Queen Elizabeth Hospital, Whare Aroha as it stands today was established as a trust in the late 1980s because the public hospital no longer provided geriatric care. Part of the Rotorua Continuing Care Trust, Whare Aroha caters for people at the lower end of the socioeconomic spectrum and is known to care for those with physical disabilities under 65 years as well. While Thérèse says many families are supportive and involved and like to visit frequently, she says they do see many sad instances where residents are literally dropped off at the door and never visited by their family. I get the impression that this only strengthens her resolve to provide high-quality care and a place they can truly feel at home. Forty per cent of the residents are Māori, which is interesting as Māori people typically don’t like to put their elders into care. Thérèse explains that this is changing, that as Māori are now living longer, whānau are becoming more aware that they can’t always provide the
level of care needed, especially for those with dementia. The Māori presence at Whare Aroha adds depth to the home. One resident teaches the other residents and the staff te reo Māori, introducing new words and phrases. “He called me his worst student,” laughs Thérèse. Formal visitors are greeted by a pōwhiri/ whakatau and the karanga has been led by a determined 95 year old lady; Thérèse described it as moving. Interestingly, Māori dementia residents sometimes revert to speaking te reo Māori, and there are staff who can converse with them. Thérèse tells me they also had a German lady who has reverted back to her native tongue, which presented more of a challenge for staff! While fluency in all languages is certainly not an expectation, Thérèse places huge emphasis on getting the staffing right. She is keen to create a participative environment among the staff. Certainly, they are a vibrant bunch, leading the residents in all manner of adventures. She shows me videos and photos on her iPhone of activities ranging from Elvis impersonations to line dancing to horse rides in the garden. “The activities are nearly always inspired by a resident’s interests,” she says, in part to explain why a horse visited the home! Thérèse says Whare Aroha will eventually have to move, as the home sits on land owned by Pukeroa Holdings, which has plans to redevelop the site. To move to a new location on the site will inevitably cause upheaval. However, it will also give the chance to build a new facility. Thérèse says Whare Aroha will have responsibility for the design of the new facility – a challenge I think she will relish. Regardless of where the building is or what it looks like, Whare Aroha is sure to retain its welcoming and friendly feel – of that I am certain. www.insitemagazine.co.nz | October/November 2012 19
On the soap-box... Julie Haggie Each issue, INsite seeks opinion on a contentious issue concerning aged care and retirement. MILESTONE REACHED IN COMMUNITY CARE
In April this year, the revised Home and Community Support Sector Standard was published, and the Government has decided that publicly funded home and community support under Vote Health must be ‘certificated’ against this Standard from September 2013. Accident Compensation Corporation (ACC) has also set this date as a requirement for ACC providers. The Government’s commitment was made last year, following recommendations from multiple parties, including New Zealand Home Health Association (NZHHA). The form of the mandatory requirement sits under contract rather than under law (as applies to other health services), but it is a good first step. People and organisations who advocated for a minimum-required standard for home support services included consumers, ACC, district health boards (DHBs), the Ministry of Health, Standards New Zealand, the Office of the AuditorGeneral, the Human Rights Commissioner, politicians, home support providers and auditors, carers, and advocacy groups. For the public, this change will offer more assurance that any agency providing home and community services through a DHB, the Ministry of Health Disability Support Services, or ACC has been audited against a common and current standard. Audit report summaries will be publicly accessible online and funding bodies will be able to access certification reports. Because this is now the main benchmark for quality, anyone seeking private services for themselves or their family should check whether the agency holds a current certificate showing that they have been audited against the Standard – its criteria are just as applicable to privately funded home support. The auditors assess against a range of criteria, including consumer rights, compliance with the service agreement, orientation, induction,
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ongoing development and competency, quality, and risk management. Certification requires a three-yearly audit cycle that includes a mid-point surveillance, as well as monitoring, to correct any outstanding issues. All members of the NZHHA hold certification. The revised standard has a stronger emphasis on outcomes and includes elements that bring it in line with new service requirements, such as an increased focus on promoting independence. It also reflects increasing complexity of need in the community through the addition of criteria on skin integrity, nutrition, infection control, challenging behaviours, and medication management. A Ministry of Health project has established transition arrangements between the old standard and the new one and auditing requirements to ensure greater levels of consistency between auditors. The project team is working on ways of ensuring that clients have more information about and easy access to complaints procedures. The lack of knowledge and data about complaints was noted by the Auditor-General in her 2011 report on the quality of home support in New Zealand. There is also work being done on ensuring a greater level of transparency around audit reports. Funders will be able to access audit reports and the public will be able to access report summaries.
The association is hopeful that the work done to ensure a minimum standard will make the quality of home support services being delivered across New Zealand more consistent
The project also aims to reduce unnecessary auditing by encouraging funders to align or combine contract audits with auditing against the Standard. There is considerable variation across funding agencies about when and how they audit against their contract. Some do not audit at all. Some run contractual audits through ‘designated audit agencies’. Other funders have different quality assurance mechanisms in place. Until now, most funders have not actually looked at a report that a provider has received following a certification against the Home and Community Support Sector Standard. Clearly, there is potential for much more discussion and learning around quality assurance between those funding the services and those delivering the services. The residential aged care sector has moved towards integration of audits and that may be a further development in home and community support. Those providers not previously holding certification to the Home and Community Support Sector Standard have some work to do to meet the September 2013 deadline, whereas providers already holding voluntary certification will not find the process as challenging. NZHHA ran a series of seminars in July across New Zealand about the requirement to meet the Standard, the transition, and the implementation process. These were very well attended by a range of providers, consumer advocates, DHB staff, auditors, and needs assessors. The association is hopeful that the work done to ensure a minimum standard will make the quality of home support services being delivered across New Zealand more consistent. It allows for more transparency in audit reporting and offers opportunities to reduce the audit burden and align contractual and service auditing where possible. Julie Haggie is chief executive of New Zealand Home Health Association.
INTERVIEW Left to right: Rotha Keo, Rotha welcomed onto marae at Waiariki Polytechnic, Rotha meets residents at The Poynton Metlifecare; Rotha and Therese Jeffs on the gondola in Rotorua.
Up close and personal with...
INsite asks Cambodian nurse, Rotha Keo, about her reflections on her three-week visit to New Zealand.
otha Keo’s visit to New Zealand was enabled by Impact Charitable Trust, a trust aimed at supporting nurses in Cambodia. The trust is led by the director of clinical nursing for Metlifecare, Kim Brooks, and the general manager of Whare Aroha Home and Hospital in Rotorua, Thérèse Jeffs. Their clinical and managerial backgrounds have enabled them to make a huge difference to nursing in Cambodia. On a recent visit to Cambodia, the trust facilitated an advanced nursing practice assessment paper at Sihanouk Hospital in Phnom Penh, of which Rotha Keo is director of nursing. Rotha spent three weeks in New Zealand in September, dividing her time between Waitemata and Lakes district health boards and a number of aged care facilities. While she was here, INsite got in touch to ask her about the differences in nursing practices between the two countries and to find out what she thought of New Zealand.
days a week with 15 days’ annual leave, six days’ sick leave, and seven days’ bereavement.
Rotha: The things I enjoy the most about
INsite: What are the main differences in terms
INsite: Has anything surprised you about
nursing are: provide training, nursing leadership management, and taking care of INsite: What are the main differences between poor and needy patients. nursing practice in Cambodia and New Zealand? INsite: What do you find most challenging? Rotha: The main differences are facilities, Rotha: The most challenging for me is the nursing technology, and the relationship lack of resources, no technology use, and not between the medical doctor with nurses. enough facilities. of patients’ conditions? Rotha: Right now, we have a lot of patients with HIV/AIDS, diabetes, HTN, and cardiac disease. We have a huge number of these diseases because most of our patients have poor knowledge, poor education, and no healthcare promotion in the community. INsite: How do the aged care facilities in
Cambodia compare with those in New Zealand? Rotha: Actually, I can’t compare the aged care facilities in Cambodia with those in INsite: What inspired you to become a nurse? New Zealand because in my country we have Rotha: What inspired me to become a only one hospital that sees adult patients nurse is I want to help, and I want to take without pay (charity hospital). Even in care of my poor people in my country, and government hospitals, patients have to pay. especially my lovely family. INsite: Are the attitudes towards caring for INsite: What does a typical working day older people similar in both countries or entail for you? different? Rotha: The typical working day in my Rotha: In my country, we don’t have older hospital is a 12-hour shift, four days a week, people centres or clinics yet. I hope that will which comes to 191 hours per month. We be in the long-term future. get 12 days’ annual leave, five days’ sick leave, and seven days special leave for family INsite: What do you enjoy most about nursing grieving. Or we can do 8.5-hours shift five as an occupation?
nursing in New Zealand? Rotha: I’m so surprised that the New Zealand Government supports the healthcare system, and that is why it makes all your people easy to live – for example, retired people. INsite: What will you take away from your
visit to New Zealand and hopefully try and implement in Cambodia? Rotha: I will take some experiences that I have learned from your country to improve my nursing department such as: professional development, nurse portfolio, early warning system (EWS), and situation behaviour assessment and recommendation (SBAR). INsite: Have you enjoyed your time in
New Zealand overall? Rotha: I enjoyed my three weeks in New Zealand so much. I had fun, was freezing, and gained a lot of knowledge to implement at my hospital. I am so grateful to the Impact Charitable Trust team, especially Sharyn Pilkington, Kim Brook, and Thérèse Jeffs, for their support, and taking good care of me, even though they spend their time and money for me, too. www.insitemagazine.co.nz | October/November 2012 21
Insite looks at how technology is transforming the services offered by retirement village operators and aged care providers. BUPA Participating in integrated electronic care plan pilot
The idea is to use it to harness technology that would allow people to stay in their own villa, in the village, longer, without having to Bupa Care Services are working with the move to the care facility. Now, all of our newest Health Alliance (HA), the support agency villages have FTTH. for three Auckland district health boards, for FTTH allows for a full data connection into three care homes within the Auckland region each dwelling. Currently, it enables Summerset to participate in an integrated electronic care to offer services such as phone and data, but plan pilot. This pilot will see the National this is only the beginning of what could be Health Shared Care Plan CCMS being introduced. integrated with Bupa’s CCMS ‘Aotahi’, We envision in the future we will be able Bupa’s centralised client database, bringing to provide Internet Protocol TV and health together the health information of those high services such as remote doctor or nurse visits users. done over the data network and even passive This multi-disciplinary approach will see an monitoring of our residents done by exception, optimal integrated care delivery supported as if desired. This would mean staff in a village can electronic health records become accessible receive alerts when a fridge door hasn’t been to primary, secondary, and tertiary providers. opened, or the hot water not used for a specified It will mean improved resident health period of time, indicating an independent information being transferred in a reliable resident may be in trouble. We also have the and secure manner. It will also enable Bupa ability to place pressure plates on the floor that to see regional lab test results, medication can alert staff when somebody has had a fall. lists, and discharge summaries. The possibilities for this kind of technology The architecture of CCMS is technically are endless. Villages can be completely similar to Microsoft Dynamics CRM used networked, so staff can access information to develop Bupa’s Aotahi. Bupa is the first on the spot and enable residents to live more private aged care provider in New Zealand independent lives, while being monitored to be part of the Regional Shared Care without it being intrusive. programme. In aged care, there is real potential for extraordinary technologies to make a real SUMMERSET GROUP difference to the lives of staff and residents. Fibre to the home: Laying the FTTH is our first step in accessing this; we groundwork for technology boom believe it’s laying a solid foundation that will set In 2007, Summerset was planning to us up for the future. build our village in Hastings and realised By Joe Byrne, IT Manager, Summerset Group Ltd we needed to look at ways we could build smarter infrastructure and technology THE SELWYN FOUNDATION to enable our residents to ‘age in place’. New client records software The ageing in place idea is in line with Hilda Johnson-Bogaerts, The Selwyn New Zealand government policy, which Foundation’s general manager for residential encourages people to stay in their homes for care services, says new client records software as long as possible. This includes retirement is transforming the way Selwyn operates. village residents, as they are in their own “Last October, the Foundation appointed homes when living in a village. Leecare Solutions to provide an innovative We decided to introduce Fibre to the client records software package for use by Home (FTTH) into all of our new villages, our managers and clinical staff at our 11 care starting with Hastings. facilities,” says Johnson-Bogaerts.
“Australia-based Leecare are the market leaders in providing electronic care planning systems to the aged care industry, and we chose them as our preferred providers after an extensive review of the software products on the market. We compared the programmes that are generally available against our requirements and compliance obligations, the match with our philosophy of work and effectiveness of care planning, as well as the overall cost, time-saving benefits to users, and the general fit with our organisation. “The Leecare software will allow us to automate all resident clinical and care management documentation. It will enable us to track and record vital resident details from admission, review care plans and progress notes, sort data, and generate reports, providing staff with timely access to accurate and up-to-date resident information. It also improves communication of information and alerts staff to events coming up. “The software uses a web browser interface, therefore, it can be used with all types of Android touch screen devices and iPads etc., so staff are familiar with its look even before they start using it. Much of the functionality replicates what they see in other websites and programmes – from selecting residents, to uploading documents and resident carefocussed videos or pictures onto the resident home page or into their assessments and care plans. “Staff training has been under way since the start of this year, and we’re in the process of introducing the new system in a phased implementation for all client records across our facilities and sites. There’s been an excellent response from our RNs, as they can see the benefits with regard to assessments and a reduction in time spent on documentation. “Ultimately, the Leecare system will improve the resident experience by having well-communicated and planned care at staff members’ fingertips.”
☛ GOT AN OPINION? Have your say online at www.insitemagazine.co.nz 22
October/November 2012 | www.insitemagazine.co.nz
... with Imelda Corby
INsite chats with Imelda Corby, secretary of the Association of Residents of Retirement Villages (ARRV) and resident at Vision Forest Lake retirement village in Hamilton. INsite: How did you find yourself in the role
of secretary of ARRV? Imelda: Very easily – I actually offered. At the meeting following the inaugural meeting – in 2009 – the three main positions had to be filled, with the chairperson obvious, but no one offering to be secretary or treasurer. So I offered. INsite: Does playing an active role in
ARRV feel like you’re still ‘working’ in your retirement?
Imelda: Yes, most often it has felt like that. A
while ago, I decided that I would be available for ARRV on Monday and Thursday mornings only. For a short while, that was magic! But then, someone wants something urgently, or I need to make contact with several people ASAP…the usual way things go, really. INsite: What aspects of this role do you
Imelda: I enjoy the fact that ARRV is now
known to a lot of people in the retirement village sector – so it is quite a buzz when someone contacts me because, say, Department of Building and Housing or some other organisation advises them to. Even Citizens Advice has made contact. It is also a good feeling to be able to give someone some guidance about their options. Though personal or village issues are not our focus, really. INsite: Which aspects do you find frustrating
or challenging? Imelda: Frustration sets in when we have gone to, sometimes, quite a lot of effort, to respond to “consultations” about some aspect of the Retirement Villages Act or Code of Practice only to find that our residents’ views must have been lost or discounted. If we only had a voice in Wellington, we would feel as if we’d have a chance of being heard. The “voice in Wellington” is the aim of ARRV – a voice in the decision-making process – because residents must be the largest group of stakeholders in the sector and we don’t have a voice. There are plenty of challenges, too. The first is to become familiar with the RV Act and all the documentation that goes with it; the second is in trying to drum up awareness among residents in all parts of the country.
After those two, come the various situations that residents ask about.
unable to be independent at all would you have to move.
INsite: What did you do prior to retirement? Imelda: I was a social worker for a lot of my
INsite: Does retirement village life fulfil your
working life, and until I retired (the first time!), I worked with several agencies and also managed a voluntary agency at one stage. So seeking justice for people and giving them tools or knowledge to achieve what they want has been pretty normal for me. INsite: What prompted the move into a
retirement village? Imelda: I found this village while accompanying someone else who was looking – and a number of things fell into place for me. For instance, environmental concerns, like urban spread – especially into good productive land – which is too unacceptable, generally, for me. So retirement villages and apartments are a more economical use of living space. That is important for me. INsite: What made you choose Vision Forest
Imelda: I’d like to say it was the design of
the village and the friendly atmosphere – and it was, but that wasn’t all of it. Equally, or more, the village is situated between a park and the local racecourse, so there is a marvellous sense of space! My outlook encompasses Mt Pirongia, the Raglan hills, and the western sky, which is superb. I’ve always loved the light, the cloud formations, and the sunsets. After these aspects, the layout of the village and the design are an added bonus. INsite: Does Vision Forest Lake have a care
facility? Is this an important consideration or not? Imelda: No. Vision Forest Lake is billed as being “for independent living”. It wasn’t a consideration for me when I came in here over six years ago, and it still isn’t. For two reasons. One is that there is no guarantee that, should you need a rest home or a hospital bed, that there would be one there when you need it. The second reason is that although this village doesn’t have serviced apartments as such, you could do quite well with the services available here, plus some home help, or whatever, available in the community generally. Only when you are
expectations? Do you feel you are able to retain your independence with security, care, and social life? Imelda: Yes, I’m very pleased I made this move and have no regrets at all. I still dabble in gardening both in and out of the village. There is a good amount of communal living, which you can enjoy or leave alone, if you wish. I like the way people respect each other’s privacy yet maintain contact. It is good to maintain some ‘outside’ interests as well, though – you have the rest of your life to try everything in the village! Save some things for when you no longer drive! INsite: What advice would you give to people
considering moving into a retirement village? Imelda: Umm ... think carefully and know why you want to live in a village atmosphere. Don’t leave it until you have little energy left for living! It is so much easier from inside a village! What to look for? Amenities that you would like – a bit of space, maybe; a social calendar that includes some of the things that you like; some sports amenities. If a dog or a cat is important for you – check out the rules. Be aware of what neighbour habits annoy you: loud music? Always popping in? Not friendly? Or keeping you for long periods as they talk? And be aware of your habits, too – will they fit in to this fairly closed community? If possible, talk to some residents who are there already – you will get an impression of residents’ satisfaction. Remember, it is an important step to take, and while nothing is perfect, it can be a most satisfying decision! INsite: What advice would you give to
managers of retirement villages? Imelda: For managers of villages like mine – for “independent living” – I wish they would work harder at encouraging ‘younger’ people to move into the village. Yes, we all get older and less independent, but unless the more active residents are present, the whole village culture slows down and activities, residents’ committees, and the vitality of the place grinds to a halt. Some villages have an entry age of 70+, whereas people in their sixties adapt very well to village life. www.insitemagazine.co.nz | October/November 2012 23
Last word... Margaret Owens
YOUR VILLAGE OPERATING MODEL – CHOOSE CAREFULLY!
here are a lot of diverse retirement villages out there in Australia and New Zealand. The operators have to decide how to run the village in the best interests of the residents and operators. Long term sustainability of that community is of paramount importance and the tone is set by the operator from the very first day. I started in the industry in 1990, when there were only six retirement villages in New Zealand. Since then, I have seen two predominant business operating models – I will call them the pastoral care model and the service model. Pastoral care requires a very energetic and engaged village manager who really cares about the residents – and I mean really cares! Cares enough to attend all the funerals, show interest in residents’ blood tests and exercise programmes, visit them in hospital and after they have left the village to move to care, is with them for their big moments – celebrations and sad times – and pops in to visit when they are ill. The pastorally
focussed manager will know all the names of the residents lead family members and won’t hesitate to stay late or come early to work if there are important things to be done. That commitment will continue through to regular engagement with the community and immediate neighbourhood surrounding the village and older people’s groups. The Service model has been adapted from hotels and the tourism sector and has been crafted from experience in villages since the mid-1990s. Here, the operator stresses a five star service ethic, which may even include 24-hour reception, uniformed staff, and often, a rather formal operating structure. Here, there seems to be less room for diversion from the mean and the job is done within office hours, staff are discouraged from helping out the residents, “after all, they do live independently”, and hold residents at arms length. In some villages, individual visits to residents’ houses are discouraged and a more
RESIDENTS’ WISHES at Christmas
Have you or your staff been fulfilling the wishes of your residents in wondrous ways? WOULD YOU LIKE TO BE REWARDED WITH $1000? If so, INsite would love to hear from you for the INsite/NZACA Residents’ Wishes competition! The theme for this year’s INsite/NZACA competition is “A resident’s wish fulfilled”. Send us your fabulous photos of how you or one of your staff members met the needs of your residents this year. It could be anything: organising a social event, offering extraordinary personalised service, or perhaps a field trip with a special purpose. If you fulfilled the wish of one of your residents, we want to know about it!
Entry information »» Send up to five photos »» (high resolution), with captions of 50 words of less. »» Prize money: $1000.
Entries via: »» Email: firstname.lastname@example.org »» Post: INsite/NZACA Residents’ Wishes competition, PO Box 200, Wellington 6140. »» Entries close 15 January 2013 »» Entries published in INsite’s February/March 2013 issue.
October/November 2012 | www.insitemagazine.co.nz
formal ‘corporate’ type environment ensues. Under the service model, everything that needs to be done gets done – usually very well and clear boundaries are maintained between staff and residents. Staff are monitored to ensure there aren’t extra things being done for residents that are not part of the “script”, or are provided free of charge – because as the saying goes, the residents are independent. The term ‘pastoral care’ has somewhat religious overtones. This is very appropriate as churches generally have a large army of volunteers that try to ensure the lives of people around them, especially the elderly and the frail, are enhanced by their involvement. This is essentially the objective of the pastoral care style of village management. There is generally no religious element in the service ethic of the operator under the pastoral care models, but the principles are much the same. Indeed, I imagine the religious and welfare operators point to this as a secret to their success. I believe that under the service model, residents remain less connected to the village because imperceptible but clear boundaries are drawn between ‘care’ and ‘service’. Just because the resident is fit and well does not mean that they do not want to benefit from a direct relationship with their village manager that touches their hearts and their souls. Genuine warmth, compassion, and attention will make the resident feel kinship, a sense of connection, and almost a collegial rapport with the village manager. This can’t be fudged, nor can it be learnt from the corporate bible; the residents will see through a manager ‘going through the motions’ at a crack! The important difference is that they are not just seeking connection and fellowship with their peer residents, they are also seeking a connection with the village manager. There are enormous benefits to this way of operating a village. When I was a village manager using this pastoral care model, I didn’t advertise for four years – every vacancy filled due to the waiting list that grew with our growing reputation for old-fashioned caring.
Residents, relatives, and members of the local community felt a deep sense of connection with each other. I attended a funeral the other day for Jack, a resident whom I had sold into the village with his late wife several years ago. Four former staff members – most of whom have been away from their jobs at that village for more than five years – were at the funeral. Although they have moved on to other career options, the deep sense of connection of that team to the village residents remained strong – showing the staff had grown as people by their very special experience in that workplace. Benefits, therefore, are not just for the residents but also for the staff who have the privilege of being involved in these special communities. The attitude and outlook that pervades this pastoral care model is that the residents and staff are in this together, working almost as a peer group. Residents are deeply respected for the contribution they can still make in the life and times of the village. The lovely late Jack delivered the newsletters until he was 98! When I started in my first retirement village, my lawyer’s mother was a resident. When I told him of my new career, he said, “Don’t you dare talk down to those people.” I like to think I wouldn’t have done that, but he focussed my mind on the importance of always respecting the lives residents have led and the contribution they could still make to their own growth and development as people. I never wanted to short-change them and have always tried to find those special people as staff members who can ‘go the extra mile’ in a meaningful way to enrich that stage of the residents’ lives. My belief is that the village operating model, whatever it is, needs to recognise that unless you offer residents an extra special connection of intrinsic value, why would they leave their home to come and live in your village? They are not craving corporate speak and an arms-length relationship – that’s for sure. Margaret Owens is the President of the Retirement Villages Association Executive Committee.
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